Alimentary Tract
Long acting release-octreotide as “rescue” therapy to control angiodysplasia bleeding: A retrospective study of 98 cases

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Abstract

Background

Gastrointestinal angiodysplasias are an important cause of difficult to manage bleeding, especially in older patients.

Aim

To retrospectively evaluate the long-term efficacy of long acting release-octreotide in controlling angiodysplasia bleeding.

Methods

98 patients with a history of bleeding due to gastrointestinal angiodysplasias lasting over 2 years were retrospectively selected among those treated from January 2000 to December 2008. All patients had received octreotide 0.1 mg tid for 28 days and, then from day 14, long acting release-octreotide 20 mg monthly, for 6 months.

Results

The mean follow-up was 78 months. In all patients mean haemoglobin levels significantly increased and the number of bleeding episodes, hospitalizations, patients requiring blood transfusions and units of transfused red cells significantly decreased, compared to the two-year observation period before starting therapy. According to outcome patients were classified as: 40 full responders (40.8%), 32 relapsers (32.6%) and 26 poor responders (26.5%). At multivariate analysis age >65 years, male sex, chronic antiplatelet therapy, chronic obstructive pulmonary disease and chronic renal failure were the only covariates independently associated with poor response to therapy.

Conclusion

Our study suggests that long acting release-octreotide could be used as rescue therapy to control bleeding due to gastrointestinal angiodysplasias in patients not suitable for endoscopic or surgical treatments.

Introduction

Gastrointestinal angiodysplasias (GIADs) are common and often asymptomatic lesions in elderly patients, but are sometimes responsible for difficult to manage acute or chronic bleeding, accounting for an overall mortality rate of 2% [1].

The use of somatostatin analogues in the treatment of bleeding from GIADs dates back to 1993 when Rossini et al. firstly described three patients with a history of chronic anaemia due to small bowel angiodysplasia successfully treated with octreotide [2]. The mechanisms by which octreotide might exert an anti-bleeding effect include: (1) improved platelet aggregation, (2) decreased splanchnic blood flow, (3) increased vascular resistance and (4) inhibition of neoangiogenesis [3]. Since the first report, several other studies have apparently suggested a beneficial effect of both octreotide and long acting release (LAR)-octreotide in controlling recurrent bleeding due to GIADs [4], [5], [6], [7], [8], [9], [10], [11], [12]. However, the nature of the studies’ design, the number of patients enrolled, the heterogeneous therapeutic schedules, the short-term follow-up and the different surrogate end-points (haemoglobin or haematocrit levels, requirement for blood transfusion or iron supplementation, number of hospitalization, etc.) used to define the response to therapy may account for the poor validity of the studies that fail to supply an unequivocal evidence to recommend octreotide in the treatment of GIADs bleeding [13], [14], [15]. As a consequence the use of somatostatin analogues is not approved for the management of bleeding due to GIADs and they are currently prescribed as off-label drugs in this therapeutic setting.

The ideal should be a randomized placebo-controlled trial, but the rarity of the disease, accounting for <5% of all gastrointestinal haemorrhages [16] and ethical principles would make such a study difficult to perform.

To provide evidence on the efficacy of LAR-octreotide in controlling the recurrent bleeding due to GIADs, we retrospectively analyzed the medical records of a cohort of patients who received this treatment with a long-term follow-up.

Section snippets

Population and study design

This was a retrospective single centre study evaluating the effects of LAR-octreotide treatment in the management of patients with GIADs.

Medical records of consecutive patients diagnosed with GIADs at the Department of Gastroenterology, Federico II University of Naples, from January 2000 to December 2008, were considered eligible for the study. The study was approved by the Ethics Committee of the Federico II University.

The inclusion criteria were: history of recurrent gastrointestinal bleeding

Patient characteristics and outcome

Ninety-eight out of 147 patients met the inclusion criteria and were eligible for the analysis. Demographic and clinical characteristics of the patients subdivided according to response to therapy are summarized in Table 1.

The mean follow-up was 78 months (range 36–120 months) and, in detail, it was extended up to 72 months in 86 and up to 120 months in 71 patients.

According to the outcome and timing of response to therapy patients were classified as follows: 40 full responders (41%); 32

Discussion

First-line treatments for GIADs, such as angiographic embolization, local endoscopic ablation, and surgical resection are largely unsuitable due to the inaccessibility or multiplicity of lesions and patients age or comorbidities [20]. Moreover these approaches, even when feasible, are not definitely effective since bleeding recurs in 30–40% of the cases [21]. Therefore, an effective and safe pharmacological agent could represent an attractive option.

During the past years oestrogen–progestagens

Conflict of interest

None declared.

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